Mental Health (Amendment) Bill Bill 8 of 1997/98 Research Paper 97/138
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The Mental Health (Amendment) Bill Bill 8 of 1997/98 Research Paper 97/138 9 December 1997 Dr. Julian Lewis MP's Private Member's Bill, the Mental Health Amendment Bill, is due to be debated on Second Reading on 12 December 1997. Its aim is to improve access to in-patient psychiatric facilities for people who do not meet the criteria for compulsory admission but who are still in need of "sanctuary". This Paper discusses the background to the Bill, including the changes in mental health legislation over the past hundred years, the shift from providing care in institutions to a policy of "care in the community", the current pressure on in-patient psychiatric beds, and conditions in psychiatric units. It then describes the Bill clause by clause and summarises the responses that have been made to it by interested organisations. Katharine Wright Social Policy Section House of Commons Library Library Research Papers are compiled for the benefit of Members of Parliament and their personal staff. Authors are available to discuss the contents of these papers with Members and their staff but cannot advise members of the general public. CONTENTS ISummary 5 II A history of psychiatric provision 7 III The balance between hospital care and care in the community 14 A. Care in the community 14 B. Availability of in-patient beds 15 C. Conditions in psychiatric hospitals 19 D. Government action 21 1. Conservative Government 21 2. Labour Government 22 IV The Mental Health (Amendment) Bill 24 V Responses to the Bill 25 Research Paper 97/138 I Summary Julian Lewis MP's Private Member's Bill, the Mental Heath Amendment Bill (Bill 8 of 1997- 98) is prompted by the concern that the way the policy of "care in the community" has been implemented in practice has led to patients who need in-patient care in a safe environment being unable to access such care. This Paper attempts to summarise some of the background to the community care debate, before summarising the contents of the Bill and the responses that have been made to it by groups representing patients and healthcare professionals. Part II of the Paper gives a brief summary of how mental health legislation has changed over the past hundred years, from the Lunacy Act 1890 to the Mental Health Act 1983. It comments on the extent to which this legislation has been concerned with the powers of the state to intervene when a person is suffering from mental disorder, rather than with the kind of services which should be provided. Part III of the Paper describes the shift to the idea of "care in the community": the principle that mentally ill people should, wherever possible, be cared for in their own homes or in community based hostels and homes, rather than in large institutions. It discusses how the implementation of this policy has been accompanied by increasing pressure on acute (that is, short-term) psychiatric beds, especially in the inner cities and discusses the possible reasons for this. These include the argument that community facilities have not developed quickly enough to replace the facilities once provided in large institutions: patients may need to be admitted to acute beds because the community services available are not sufficient to cope with a relapse or acute episode of their illness; alternatively, patients may remain in acute beds, even though they do not need acute care, because of a shortage of other facilities to which they could be discharged, such as longer-term nursing care or supported housing in the community. This Part of the Paper also looks at the conditions in psychiatric units and at the policy announcements on care in the community and its relationship to in-patient care by both the current and previous Governments. Part IV summarises the Mental Health (Amendment) Bill. Clause 1 of the Bill would require each Health Authority in England and Wales to prepare a strategy for the provision of in- patient care for those in need of it, monitor progress towards implementing the strategy and make an annual report to the Secretary of State on that progress. Clause 2 would require Health Authorities to ensure that all in-patient beds in existing psychiatric units are provided in single-sex ward areas and that all room and ward doors are provided with adequate locks. Clause 3 makes the same provision for future psychiatric units. Part V describes the responses to the Bill by organisations representing people suffering from mental disorders and from the healthcare professions. The move to legislate on single-sex 5 Research Paper 97/138 wards is generally welcomed, but the response to the requirement to prepare a strategy on in- patient provision is more mixed: some organisations have welcomed it as a way of making Health Authorities give higher priority to in-patient psychiatric provision, while others believe it will not achieve this aim and will simply create added bureaucracy. 6 Research Paper 97/138 II A history of psychiatric provision Most of the legislation affecting the provision of psychiatric care in England and Wales focuses not on the kind of care patients should receive, but on the powers of the state to intervene when an individual is suffering from mental disorder and is deemed in need of treatment. The current legal framework is found in the Mental Health Act 1983, which is a consolidation of the Mental Health Act 1959 and the Mental Health (Amendment) Act 1982. Amendments to the 1983 Act have since been made by the Mental Heath (Patients in the Community) Act 1995 to allow for patients to be "supervised" in the community once they have been discharged from hospital. Whilst significant changes were made by the 1982 and 1995 Acts, it was the 1959 Act which signalled a fundamental shift in approach to the care and control of people suffering from mental illness. Before the 1959 Act, the relevant legislation for mentally ill people was found in the Lunacy Act 1890 and the Mental Treatment Act 1930. The former provided for poor law officials or relatives to apply for a judicial order to "certify" a "lunatic", so that he or she could be placed in an asylum. The application had to be accompanied by medical evidence and, according to Brenda Hoggett's summary of the history of mental health legislation,1 doctors often shrank from using this power, because of the stigma involved. It has been suggested that this then meant that when patients were, finally, certified, it was too late for treatment to be of any help. It also meant that there was little, if any, provision for those suffering from mental disorder falling short of "lunacy", unless they were able to pay as a private patient. The Board of Control (known up to 1913 as the Lunacy Commissioners) was empowered to supervise standards and protect patients in both public and private institutions. The Mental Treatment Act 1930 introduced for the first time the idea of "voluntary" patients in public institutions (formerly the Maudsley hospital was the only hospital permitted to accept non-paying patients without certification). The Act thus began to move the emphasis of psychiatric care towards informal admission and treatment, and away from mere institutional containment. As a result of the 1930 Act, there were from then on three categories of patient: "certified" patients under the 1890 Act, "temporary" patients (non- voluntary patients requiring treatment for less than a year) and voluntary patients (those able to make a written application to be treated in hospital). Asylums were also renamed "hospitals" and "lunatics" became "persons of unsound mind". However, "persons of unsound mind" who had been certified under the 1890 Lunacy Act could still only be placed in "designated" public mental hospitals, "registered" hospitals or "licensed" private nursing homes, and thus psychiatric institutions continued to develop quite separately from mainstream hospital provision. 1 Brenda Hoggett, Mental Health Law, 1990 p.8 7 Research Paper 97/138 The 1959 Act was described by Hoggett as "revolutionary". It enabled mentally ill patients to be admitted to hospital like any other patient (with compulsory admission and compulsory treatment only to be used where strictly necessary); it enabled mentally ill patients to be admitted to any public hospital, rather than being kept separate in designated institutions; it brought the legislation governing those with mental illness and those with learning disabilities together; and it aimed to reduce the stigma of being labelled mentally ill. Kathleen Jones, in Asylums and After2 sums up the provisions of the 1959 Act as follows: "1. The Act repealed all previous lunacy, mental treatment and mental deficiency legislation, and provided a single code for all types of mental disorder. 2. 'Mental disorder' was defined as 'mental illness, arrested or incomplete development of mind, psychopathic disorder, and any other disorder or disability of mind'. 3. The Board of Control was abolished, existing officers being transferred to the Ministry of Health. The Board's functions of inspection and review were transferred to local health authorities. 4. Local health authority mental health services provided under section 28 of the National Health Service Act 1946 might include the provision of residential accommodation, centres for training and occupation, the appointment of mental welfare officers, the exercise of the functions of guardianship and 'the provision of any ancillary or supplementary services'. 5. Mental Health Review Tribunals, organised on a regional basis, took over the 'watchdog' functions of the Board of Control in individual cases of compulsory detention. They were to consist of legal members, medical members, and 'members having such experience in administration, such knowledge of the social services, or such other qualifications and experience as the Lord Chancellor considers suitable', to be appointed by joint consultation between the Lord Chancellor and the Minister of Health.